The term ‘poor GP-hospital liaison’ sounds deceptively neutral when one looks at what really is at risk here – patient safety. In this article we look at case vignettes from GPs which signify that generally, the under-pressure system is dysfunctional and inefficient, although the quality of hospital-GP liaison can vary.

GPs’ negative experiences of hospitals tend to revolve around three areas: poor access for patients to diagnostics, specialist consultations and treatments; communication practices such as uninformed discharge letters from inexperienced NCHDs in EDs; and hospitals dumping work on GPs. Some GPs say they are often lucky to get any discharge summary, and it can often take months to get a response to a request for an outpatient assessment. It appears the only way a GP can try to get a patient admitted or seen quickly is through the ED.

In the following articles we look at ways in which hospital-GP links can be made more efficient. One initiative has led to better hospital-GP links and improved patient care, while a new study highlights deficiencies in discharge summaries for psychiatry patients and suggests ways in which these can be improved.

Noreen Lineen Curtis, Co Mayo: 

I was recently treated faultlessly as a patient in an eight-bed public ward. Every staff member I encountered carried out their jobs impeccably, and the care was excellent. Most of my patients have had the same experience once admitted.

So why are so many of us unhappy with the overall performance of hospitals? One of my bugbears is communication. The length of time it takes for GPs and/or patients to get a response from some departments is appalling. I will send a patient in, perhaps for an OPD assessment for medical or surgical management, and I will sometimes not get a response to that visit for up to eight months. 

It’s all very well if the patient can tell me exactly what happened and what the management plan is following the assessment, but often they have no idea and it’s most frustrating to get a letter maybe six months later, directing that a medication be changed with a plan to review the patient in six months time to assess their response.

The delay from certain departments is worse than others. Some are fantastic, a case in point being our local radiology department. They have adopted NIMIS (the National Integrated Medical Imaging System) with voice-recognition technology for reporting, and once a patient has had an investigation, I will have a report within 24 hours.

Why then, when you look behind the scenes, are there mountains of patient charts, while secretarial staff tap on keyboards to get a completely outdated letter out to a GP? 

Why can’t we instal proper IT communication systems on a nationwide basis? This would save time and money, and I would not have to endure another consultation with an elderly lady, asking her what the consultant said while she looks blankly at me and says “Well, I don’t really know doctor. I was hoping you would.”

Patricia Carmody, north Dublin:

I think communication from hospitals has got a lot better in recent years and I would be fairly happy with it. Once your patient gets into a hospital for treatment, the care is generally excellent.

However, a major source of frustration is outpatients, where I find the service to be very poor.

Often, even though I give detailed referral letters, the consultant will designate the case as routine. The patient could, for example, have severe back pain with disc prolapse, having had to privately pay for an MRI. I think orthopaedics and gynaecology are the worst in this regard.

Eamonn Shanahan, Co Kerry:

The hospital service and general practice are both like glasses of water, full to the brim. Transferring a few drops in either direction will cause an overflow.

Our bugbear is the increasingly frequent requests by hospital staff of all grades and disciplines to us to carry out various tasks. “Please recheck Mrs A’s U&Es in a week’s time”. “Please carry out ABPM for Mr Z”. “Please arrange paediatric outpatients for Ms K”.

As a convenience to patients, we carry out phlebotomy, venesection, INR checking and ABPMs. I have no issue with this. What I do object to is the presumption that we will carry out this work even when generated by the hospitals.

The other side of the coin is hospital staff are demoralised; I really fear that the spirit of Mid-Staffordshire is creeping into our services.

The solution is capacity building. Identify where hospital and GP services are struggling and employ more staff. The big issue is timely access to diagnostics – and this doesn’t just mean radiology. Much of what is needed isn’t rocket science. Investigations ordered by clinicians of sufficient seniority to understand the need for the tests and who will take clinical responsibility for the outcomes, will have significant impact on patient care. 

Paul Stewart, Co Donegal

“Could you put me through to the medical house officer on call please?”

“He’s not answering his bleep.” 

“Can you try him again, this is the third call I’ve made.”

“Yes, medical on call.”

“Good evening, this is Paul Stewart, GP in Dunfanaghy. Who am I talking to? “

“Medical on call!”

“I’m ringing up about an admission. Michael is an 82-year-old, living alone with what looks like a UTI. He has an indwelling urethra catheter and has been on the waiting list for a TURP for over four years now. He has become very confused with a pyrexia of 38.4 and I think he needs IV antibiotics”.

“UTIs are surgical!”

“I’ve been on to the surgical SHO and she says they’re medical”.

A week later, I get a call from Michael’s home help. He’s been discharged back home without any warning, to a cold house on Saturday night and needs his discharge meds. Luckily I am able to get a pharmacist open on Sunday afternoon and Michael’s home help kindly agrees to go 15 miles into town to get the antibiotic.

On reviewing the discharge letter, which arrives a week later, he has been discharged on an antibiotic, but two of his routine medications appear to have been stopped without explanation in hospital. One of the meds was for warfarin treating Michael’s Afib.

After another three phone calls to the medical team on Monday morning, I establish that these meds were inadvertently left off the discharge prescription.

A week later I get a discharge summary. I discover a sentence stating that the GP should do a U+E after a week. Luckily I spotted this but realise that it will involve another early morning house call on our blood collection day; maybe I can also change his catheter while I am out there. We need good communications, professional courtesy and better discharge planning. 

Peter Sloane, Co Galway:

Tadhg is 86. He recently arrived on his bike to tell me that he’d been feeling very weak for the previous few weeks. He had last been in four months earlier. At that visit he told me his eyesight was getting worse and his left hip was badly at him. Tadhg is an infrequent attender who doesn’t complain until things are bad. Four months ago his bloods and BP were good, but he needed referral for a cataract and to have his left hip assessed. Referral letters duly done, at that time we made an appointment for six months. I didn’t have the heart to tell him how long the waiting lists are. 

Now, he was clearly unwell but with nothing focal, and had lost weight. The cataract had got worse, the hip was now severely paining him. I rang the local MAU. No appointments over the next four days. I sent him to the ED. To my horror, the following day he came back to me with his ED discharge letter; from the SHO. He didn’t even get a medical review. It said his bloods were OK and ECG and CXR were fine. No-one had read my letter. The letter suggested I write to orthopaedics and ophthalmology, repeat bloods in a week and consider referring him to geriatrics and physiotherapy! 

After 15 minutes on the phone I eventually got the ED, but the SHO wasn’t working; no-one was free to talk. I’m left with no way to speed up his hip (OPD wait now over two years), or his cataracts (long wait); no access to the hospital other than via a dysfunctional ED.

Over the next few days Tadhg got weaker and clearly more ill with no obvious cause – I had to send him back. This time he got admitted after 40 hours on a trolley and spent two weeks in the hospital. He’s now home and doing OK. 

We need a hospital system that puts the patient at the centre. As our population ages, we need huge investment in primary care; hospitals need fewer managers and administrators and more beds and front-line doctors. 

There should be more consultants and better team-working. Why not revert to the old system of direct GP admissions into beds?

Brian Osborne, ICGP assistant medical director:

Mrs R is a 46-year-old female with a history of mild gastritis on endoscopy from three years previously. She presents with a two-week history of epigastric and right upper quadrant pain associated with intermittent nausea. 

Her examination is unremarkable apart from some mild epigastric tenderness. LFTs are sent and she is commenced on a PPI. LFTs show mildly raised transaminases. She is informed she may have gallstones and is referred to surgical outpatients as there is no access to ultrasound for public patients in the community. She is seen in outpatients four months later and told she needs an ultrasound. 

While awaiting an ultrasound her pain worsens one Saturday evening. She attends the ED, is seen by a NCHD and is given pain relief and a letter to bring back to her GP. The letter advises her GP to arrange an ultrasound and that she needs her blood tests repeated as her LFTs were abnormal in the ED. 

Her GP tries to explain the process again. Two months later she has an ultrasound. She re-attends outpatients to obtain her ultrasound result and this confirms gallstones. She is listed for surgery. 

Her GP suspected a diagnosis but could not confirm it due to lack of access to diagnostics. She subsequently had two outpatient appointments, one ED attendance and a subsequent visit to her GP when all she required was an ultrasound and subsequent referral to outpatients with the diagnosis confirmed. 

The patient was put through needless waiting and anxiety. The outpatient and emergency department attendances were unnecessary and her GP is left frustrated with a lack of access to diagnostics, increased unnecessary attendances at an overstretched practice and an uninformed letter from an inexperienced NCHD in the ED. Access to a basic investigation such as ultrasound would have prevented this.

Rita Doyle, Bray, Co Wicklow:

I noticed that something wasn’t right about John as soon as I saw him in the waiting room – he’s been a patient of mine for nigh on 30 years. He was supported by his wife as he hobbled in. He told me a story of a severe head injury, a spell in ICU, following which he was discharged the previous day – no letter for me, no communication, and a prescription for dihydrocodeine.

Seven phone calls later I got a promise of a summary – 48 hours later I got a ‘copy and paste’ letter. With the help of John’s wife, I managed to piece together the bits. Severe head injury, pneumonia and a sight problem as a result. I gave him guidance on how to proceed and had him seen by our community ophthalmologist.

He was due back to outpatients in six weeks with a CT scan needed beforehand.

No scan had actually been arranged by the hospital; I managed to sort this out. At outpatient review the registrar asked him why he was there – he told his story and the reply was “I’m very sorry, I’m a gastroenterology reg and know nothing about head injuries.”

“But I was under the care of your consultant,” John protested! No reply. How was the scan, he asked. “I don’t know – it’s not here.”

The reg left to try and find the x-ray and came back to tell him it was there but she could not read it. She suggested that he should be followed up in another hospital and that she’d write for an appointment – you can guess how long that would take.

The CT scan is still not reported on, so as usual we in general practice are left to pick up the pieces. Apart from the workload fall-out, this sort of situation shows a total lack of respect for the patient, whose time is just as important as the doctor’s. 

Margaret O’Riordan, ICGP medical director:

One of the bugbears GPs have is poor discharge information from hospitals, often from very junior doctors. The quality of the discharge process tends to vary from hospital to hospital, but often both the patient and the GP are left in the dark about follow-on treatment, medication or what type of investigations etc were carried out in hospital.

One area of concern is the potential for medication errors or omissions. Doctors will get a list of medications in a discharge summary. Often it will be unclear whether or not this is a list of new medicines to replace the previous meds, or in addition to the existing drugs being taken. Often you get difficult-to-read handwritten notes. It can sometimes take up to six weeks to get a full discharge summary. Sometimes, if the patient is returning from the ED, you will be lucky even to get a discharge letter.

These inefficiencies, of course, lead to time-consuming and frustrating follow-up calls to the hospital trying to find a (usually very junior) doctor who was dealing with the patient. While obviously hospitals are under-resourced and under-pressure, these inefficiencies can put patient safety at risk. We need a properly functioning system. Standardised discharge protocols are being piloted. This needs to be rolled out nationally.

Seamus Clarke, Co Monaghan:

A recent personal experience: An elderly patient presented with symptoms suggestive of malignancy of the genito-urinary system. Physical examination confirmed a possible source. It required the patient to have access to investigations in our local hospital. Waiting times in the hospital for routine ultrasound run to many months. An urgent request for ultrasound was however, accepted within two weeks. The report which arrived one week later confirmed a tumour requiring a specialist opinion in a Dublin hospital. This required a further almost two-week wait. 

The patient was seen at the specialist clinic. It took three weeks for me to discover by letter that neither the specialist nor his colleagues had the capacity to operate on my patient. The letter advised me to refer to another specialist clinic capable of doing so. 

The patient then had another two-week wait before he could be seen at another hospital. He now finally goes on a waiting list to have this tumour removed. Eight weeks have passed and still no operation.

Most of the delays here have been due to lack of staff both at a technician level to do ultrasounds, lack of specialist capability in the region and the swamping of the hospital service due to lack of consultant operating time. This story is probably not unusual for public patients.